Interventions for promoting
reintegration and reducing
harmful behaviour and
lifestyles in street-connected
children and young people
Esther Coren1, Rosa Hossain1, J ordi Pardo Pardo2, Manuela Thomae1,
Mirella M.S. Veras2, Kabita Chakraborty3
Approval date: 20 February 2012
Publication date: 1 September 2012
2 The Cam pbell Collaboration | www.cam pbellcollaboration.org
Table of contents
T ABL E OF CONT E NT S 2
BACK GR OUND
Description of the problem
Description of the intervention
How the intervention might work
Why it is important to do this review
OBJ E CT IV E OF T H E R E V IE W 10
ME T H ODS
Criteria for including studies in the review [PICOS]
Search methods for identification of studies
Data collection and analysis
ACK NOW L E DGE ME NT S 22
R E F E R E NCE S 23
F IGUR E S [IF ANY , OT H E R W ISE DE L E T E ] 27
CONT R IBUT ION OF AUT H OR S 29
DE CL AR AT IONS OF INT E R E ST 30
SOUR CE S OF SUPPOR T
3 The Cam pbell Collaboration | www.cam pbellcollaboration.org
1.1 D E S C R IP T ION OF T H E P R OB L E M
The number of street-connected children and young people worldwide has been
estimated at around 100 million (UNICEF 2002), although this figure is widely
contested. It is recognised that exact numbers are unknown and estimates vary, due
in part to political motivations (CSC 2011). Numbers differ depending on whether
estimated by governments or non-government organisations (NGOs), and the
definition and status of the problem has traditionally differed for Europe and other
high income countries, although some of the structural antecedents such as
inequalities or social exclusion may be similar. For example, a minimum of 66,000
first-time runaways per year is recorded in England (CSC 2009), and Canada’s
street-connected children and young people may be runaways who have escaped
sexual or physical abuse. Data for the US estimate 1 to 2 million ‘street involved
youth’. The difficulty in estimating numbers is in part due to wide variations in
definitions of which young people are included and the lack of formal identity
papers, for most street-connected children and young people.
The definition of ‘street-connected children and young people’ can overlap with
other categories such as runaways and homeless youth, children who have been
trafficked, child labourers, migrant children, children who live in slums, and
children living in institutions (Ennew 2003; UNICEF 2005). Many commentators
argue that the issues prevalent in the lives of street-connected children, including
the risks, do not differ for other children living in urban or rural poverty, and that
approaches to the issue of street-connected children and young people should not be
disconnected from approaches to ameliorate poverty and social exclusion more
generally (CSC 2011; Panter-Brick 2002). This review however focuses on street-
Definitions, too, are much debated and contested, particularly in light of the
research that highlights young people’s agency and resilience (Beazley 2003; Van
Blerk 2006). Qualitative studies conceptualise agency as an element of young
people's resilience-building capacity, enabling street-connected children and youth,
for example, to negotiate for their basic needs, draw on social support networks, and
explore pathways to achieve their personal goals in a resourceful manner (Theron
2010). A summary from the overview by the Consortium for Street Children (CSC)
states: "street children are recognized to be young people who experience a
combination of multiple deprivations and 'street-connectedness’" (CSC 2011).
4 The Cam pbell Collaboration | www.cam pbellcollaboration.org
Children and young people may live and work on the street or in public spaces, work
on the street and return to family homes or hostels at night, or a combination of
these at different time periods. For the most part, they experience complex social
and economic circumstances that "defy easy definition" (CSC 2011).
Current thinking sees this process as non-linear, with many street-connected
children and young people transitioning off the streets (Panter-Brick 2002). This
definition opens the door to studies of young people living in slums/squatter
settlements or in hostels, who are also working on the street. In our systematic
review, the term ‘street-connected children and young people’ is used to refer to
children who work and/or sleep on the streets and may or may not necessarily be
adequately supervised or directed by responsible adults, and includes (but not
exclusively), the coexisting categories referred to by the United Nations
International Children's Emergency Fund (UNICEF) as those ‘on the street’ and
those ‘of the street’ - ‘children for whom the street is a reference point and has a
central role in their lives’ (CSC 2011; Redes Rio Crianca 2007; UNICEF 2001a). In
the historic UNICEF definition, ‘children of the street’ are homeless children who
live and sleep on the streets in predominantly urban areas, living with other street-
connected children and young people or homeless adults. ‘Children on the street’
earn their living or beg for money on the street and may return home at night, and
maintain contact with their families. Such definitions may include children who are
stateless or migrating, with or without their families.
Important risks faced by street-connected children and young people are physical,
psychological and sexual exploitation, violence, economic exploitation, social
exclusion, no skills-based employment, substance misuse, widespread addiction,
and HIV (Ennew 2000; West 2003). Many street-connected children and young
people experience health difficulties, coercion and control by adult gangs,
criminality and lack of education (West 2003). However, street-connected children
and young people are not a homogenous group. Current research demonstrates that
girls and young women may experience risks differently to boys and young men
(Beazley 2003; Van Blerk 2006). Other groups, such as disabled youth or those from
minority ethnic groups, may also have different experiences.
Children live and work on the streets in different ways and for different reasons
(UNICEF 2005). Most street-connected children and young people are not orphaned
but are in contact with their families and may augment the household income
(UNICEF 2005). Current research also emphasises the resilience of street-connected
children and young people and the fact of children and young people’s agency and
citizenship, making their own decisions and with a need for participation, not solely
protection (CSC 2011; Panter-Brick 2002).
1.2 D E S C R IP T ION OF T H E I NT E R V E N T I ON
Interventions aiming to improve the situation of street-connected children and
young people include educational projects (Ouma 2004), vocational training (Ali
2004), harm-reduction (Poland 2002), HIV prevention (Rotheram-Borus 2003),
and projects focused on substance use, social stability, and physical and mental
health (Slesnick 2007). They often take the form of single projects, drop-in centres
5 The Cam pbell Collaboration | www.cam pbellcollaboration.org
or peer education interventions, and many of these projects will be underpinned by
the ‘children’s rights’ discourse, more recently taking a holistic approach to the
needs of the young people (CSC 2011; Ennew 2000). Indeed, it has been argued that
some interventions may not succeed if they ignore children’s voices and do not
include their participation in planning and management (Panter-Brick 2002).
Educational projects offer street-connected children opportunities to break out of
the cycle of poverty. Occasionally, these projects help children/youth to sit formal
examinations and obtain recognised certificates (Ouma 2004), while vocational
training aims to develop skills to lead children/youth into the world of non-
exploitative work. Often these programmes aim, through health and nutrition
programmes, to increase the ‘educatability’ of children/youth before or while they
are attending schools. They can also take the form of non-formal education,
consisting of any form of systematic learning activity outside the framework of the
formal system. Such provision may be run alongside formal schooling, or separately.
Several considerations are relevant with reference to the intervention population. So
far, we have particularly identified gender, ethnicity, religion, disability, citizenship,
legal status, and age of the street-connected children and young people as relevant
individual factors that may impact on outcomes of interventions. There are also
relevant contextual factors, which include the experience of sexual abuse, violence,
addiction, low literacy, migration (including rural-to-urban), poverty, and
mechanisms of exclusion (such as negative community responses to the children's
migratory/refugee status, and labelling them as ‘vagrants’, ‘illegal vendors’, or
It is also important to consider the nature of strategies for engaging young people at
street level that, according to a wealth of qualitative literature drawing on
ethnographic data and practitioner perspectives, form the basis of successful
intervention programmes (CSC 2011; Ennew 2000; Karabanow 2004; Panter-Brick
2002). "To determine the ‘type’ of intervention needed, engagement enables a
relationship and trust to be built. Participatory models of engagement ensure that
sufficient time and space is given to children to demonstrate to outsiders why they
came to the street, and what their background is. Participatory engagement allows
children themselves to tell their histories rather than have to directly answer
questions about their past" (Walker 2011 [pers comm]).
1.3 H OW T H E INT E R V E NT I ON M IG H T W OR K
We have developed two preliminary logic models to capture the broad range of
different approaches found in interventions for street-connected children and young
people (Figure 1 and Figure 2). According to the Kellogg Foundation’s Logic Model
Development Guide, a logic model is "a systematic and visual way to present and
share your understanding of the relationships among the resources you have to
operate your progam [sic], the activities you plan, and the changes or results you
hope to achieve" (Kellogg Foundation 2004). A logic model illustrates the
connection between the work planned in an intervention and its intended results.
Anderson 2010 described how logic models could be used at different stages of a
systematic review, from conceptualising the review focus, to clarifying the
interpretation of results. They argue that logic models offer a particularly useful tool
6 The Cam pbell Collaboration | www.cam pbellcollaboration.org
in the analysis of complex interventions that operate at individual, group and social
system levels in the fields of education, health, and social welfare. Drawing on this
approach, we aim to use logic models in a dynamic way, developing and adapting
our chosen models in response to relevant stages of our review (e.g. identifying
effect mediators or moderators; subgroup analysis) and different audiences (e.g.
policymakers and practitioners). This will aid us in communicating the results from
what we anticipate, on the basis of previous studies (Altena 2010; Slesnick 2007), to
be very heterogeneous data, in a format that is both methodologically and
theoretically informative and increases the accessibility of our findings.
Inputs in the two logic models in Figure 1 and Figure 2 describe the resources which
are needed to implement an intervention for street-connected children and young
people. The term 'activities' refers to what any intervention might do with these
inputs. They are the processes, tools, events, technology, and actions that are an
intentional part of the intervention implementation. Outputs are the direct products
of the intervention activities and may include types, levels, and targets of services to
be delivered by the intervention. Outcomes are specific behavioural, knowledge,
skills, status and functional changes in the intervention participants. Sources differ
in their proposed timeframes for distinguishing short, medium, and long term
outcomes. In the two logic models we define short term outcomes as outcomes
which occur within the lifetime of the intervention, and medium term outcomes as
outcomes which occur within one to three years of the intervention. Long term
outcomes can also be defined as ‘impact’, which is the fundamental intended or
unintended change occurring in organisations, communities, or systems as a result
of intervention activities within three to seven years (Kellogg Foundation 2004).
These may however be difficult to identify or attribute to intervention inputs.
The logic models (Figure 1 and Figure 2) can be read from left to right, and in this
way describe intervention impact over time, from planning through to results.
According to Kellogg Foundation 2004, it is useful to read logic models following the
chain of reasoning (“if...then...”), connecting the different parts of any intervention.
The two logic models we present are drawn from a range of qualitative, quantitative
and narrative/overview sources (Gleghorn 1997; Kipke 1997; Kristof 2009; Ouma
2004; Slesnick 2007). An (limited) example of reading the logic model in Figure 1
In order to engage street-connected children and young people in education, an
intervention would need teachers and teaching materials, but also food, toilets and
possibly sleeping facilities (inputs). If these are available, then the intervention
could provide the children with opportunities to play and earn money. The
intervention would also need to overcome the need for school uniforms by either
providing them free of charge or not making uniforms a requirement (activities).
The immediate output of this intervention may be that lessons are taking place
(output). The intermediate outcome would be that children/young people attend
these lessons. A short term outcome (i.e. within several months to one year) might
be that children attend the lessons regularly, are not malnourished and gain self-
esteem. Within one to three years these children can read and calculate, and are able
to secure employment (medium term outcomes). In an even longer term
perspective, this may lead to reintegration and greater inclusion in families and/or
society and possibly reduce future poverty (impact).
The lower box highlights contextual factors that affect the impact of an intervention
or programme on individual children/young people, via the moderating effects of
7 The Cam pbell Collaboration | www.cam pbellcollaboration.org
resilience factors conceptualised as internal and external assets, processes, and
agency (Theron 2010). These contextual factors include age, gender, religion, legal
status, addiction status, and other factors. They constitute factors present at the
start of an intervention that may impact on outcomes or take-up of interventions.
The logic model depicted in Figure 2 is more varied in its focus and includes aspects
of health care, HIV prevention, pregnancy prevention, but also access to
employment. As in Figure 1, the model needs to incorporate street-connected
children and young people’s interests, but also their strength and resilience in order
to become involved in the intervention. Inputs include the availability of services
(outreach workers, mental health services) but also ways of addressing basic needs
such as housing and nutrition (inputs). If these inputs are achieved, activities need
to include ensuring that the new environment is safe, includes learning
opportunities, but also access to health care and condoms (for example). Outputs
that need to be achieved are that street-connected children and young people know
of and attend the intervention project, take-up health care and use more condoms.
Within the life of the intervention, these components should lead to reduced risky
drug use, health improvements, and increases in employment opportunities (short
term outcomes). Within one to three years the intervention should then result in a
reduced number of infections with HIV and other sexually transmitted infections
(STIs), but also in a reduced number of pregnancies and generally better health. The
intervention's longer terms impact (three to seven years) may be reintegration into
families, communities and society, and reduced poverty. It may however be difficult
to measure or demonstrate these longer term impacts.
A final point to be made is that the circumstances of street-connected children and
young people as noted above, may be non-linear, and young people may continue to
live/work on the streets whilst engaging with interventions, and may take many
years to reintegrate fully or become re-included within mainstream society.
1.4 W H Y IT IS I M P OR T A NT T O D O T H IS R E V IE W
The rationale for this review is to assess the effectiveness of interventions for
improving outcomes for street-connected children and young people and reducing
the risks of the most adverse outcomes, to promote access to and integration into
education, training, and employment opportunities, and more healthy and settled
lifestyles. Such lifestyles include access to universal human rights such as survival,
development, participation, and inclusion, although these may be difficult to
By addressing the above-mentioned outcomes, we explicitly aim to synthesise the
evidence on reintegration approaches, including harm-reduction programmes. We
propose to focus on inclusion, reintegration and harm-reduction interventions
targeted at children and young people while they are living on or closely connected
to the streets.
For the purposes of this review, we define reintegration as the children and young
people entering a residential and/or educational environment that has the potential
to provide them with elements of physical safety, medical care, nutrition,
counselling, education, inclusion in social and economic opportunities, and room for
8 The Cam pbell Collaboration | www.cam pbellcollaboration.org
recreation and personal and spiritual growth that may impact positively on longer
term life chances. Reintegration does not mean returning the children to the
situations from which they may have escaped. Family reintegration is potentially a
highly valuable outcome for many street-connected children and young people.
However, the effectiveness as well as ethical implementation of interventions aiming
at family reintegration, are premised on access to appropriate resources for
assessment, support and follow-up, in recognition of the potentially significant risks
associated with processes of family reintegration (Thoburn 2009).
‘Harm-reduction’ is an umbrella term to describe the interventions aimed at
reducing harms associated with lifestyles of street-connected children and young
people, including for example, those associated with early or risky sexual activity
and substance use (UNICEF 2001b). Expressed in general terms, these would be
interventions aimed at street-connected children and young people, and aiming to
protect and promote both their welfare and their well-being while they are on the
street so that they are able to benefit from more focused reintegration approaches
when it is appropriate and possible for them to do so. All the long term
recommendations we found at the UNICEF evaluation database are structural.
However, the short term recommendations by UNICEF are based on principles of
child protection that can be described as matching the harm-reduction approach.
This is open to interpretation, but seems in line with the opinion of people working
with street-connected children and young people consulted by members of our
team: protection may be a necessary stage on the path to reintegration, alongside
development and participation.
We will use the World Health Organization (WHO) definition of 'inclusion'.
'The primary aims of policies/action aimed at reversing exclusionary processes
should be to:
• promote full and equal inclusion in social systems;
• provide universal access to living standards which are socially acceptable to all
members of a society, including access to the same level and quality of health
and educational services, safe water, sanitation and ‘decent work’, as defined by
the International Labour Organization (ILO);
• respect and promote cultural diversity;
• address unequal inclusion as well as situations of extreme exclusion' (WHO
We believe that the results of a systematic review such as the one proposed here
might be relevant to a large number of street-connected children and young people
worldwide. The review will examine interventions that enable children to live safe
and healthy lives that promote their rights, and support their pathways to
adulthood. It will also highlight gaps in the current evidence base.
We identified few rigorous reviews on the effectiveness of interventions to support
street connected children and young people through a scoping search. Descriptive
reviews of interventions which include literature on lower-middle-income and low-
income countries Peters 2004 include CSC 2011; Dybicz 2005; Karabanow 2004;
and Slesnick 2007. Moore 2005 and Sanabria 2006 present descriptive reviews
focusing exclusively on US-based interventions. While these reviews provide useful
analyses and classifications of the literature, their search strategies are often poorly
9 The Cam pbell Collaboration | www.cam pbellcollaboration.org
described or limited in scope. Furthermore, they do not contain rigorous evaluation
We identified one review which included interventions for ‘homeless youth’,
described as systematic Altena 2010, where studies were reported to have been
systematically rated for study quality using a consistent tool. This review is both
recent and inclusive of literature in developing countries (language criteria not
specified). It searched the following databases: PsycINFO, ERIC, MEDLINE,
Cochrane, Google Scholar, EMBASE and CINAHL, for studies conducted 1985–
2008. Out of 557 unique search results, twelve studies were included for final
evaluation. In comparison, the current systematic review is considerably broader in
scope, both in terms of the number of databases searched and the breadth of our
search terms. However, to avoid duplication our systematic review takes into
account the existence of a Cochrane review on HIV/AIDS prevention with homeless
youth Naranbhai 2011, as discussed below.
10 The Cam pbell Collaboration | www.cam pbellcollaboration.org
2 Objective of the review
Primary research objectives
To evaluate and summarise the effectiveness of interventions for street-connected
children and young people that:
• promote inclusion and reintegration ;
• increase literacy and numeracy;
• increase access to education and employment;
• promote mental health, including self-esteem; and
• reduce harms associated with early sexual activity and substance misuse.
Furthermore, to explore what can be known about the processes of successful
intervention and models of change in this area, and understand how intervention
effectiveness may vary in different contexts.
Secondary research objectives
1. To explore whether effects of the intervention differ within and between
populations, and whether an equity gradient impacts on these effects including
and importantly, extrapolating from all findings relevance for low-middle
income countries (Peters 2004).
2. To describe other health, educational, psycho-social, and behavioural effects,
where appropriate outcomes are available.
3. To explore the influence of context in the design, delivery, and outcomes of the
4. To explore the relationship between the number of components, duration, and
effects of the interventions.
5. To highlight implications for further research and research methods to improve
knowledge of the interventions in relation to the primary research objective.
This review will also consider potential adverse or unintended outcomes. Some
outcomes identified in the literature include negative effects of poorly planned or
forced interventions (CSC 2011) and detrimental outcomes frequently documented
in association with reintegration of children in non-family care into their families of
origin (Thoburn 2009). A possible adverse outcome that may, however, not easily be
captured in study evaluations is an increase in street-connected children and young
people’s mistrust of adults in the context of interventions that may be ad-hoc and
short-lived due to lack of funding and other structural support. Study designs that
do not provide genuine opportunities for children and young people’s participation
throughout the research process are most likely to fail in assessing the full range of
outcomes of an intervention (Panter-Brick 2002; Slesnick 2007).
11 The Cam pbell Collaboration | www.cam pbellcollaboration.org
3.1 C R IT E R IA F OR I NC L U D ING S T U D IE S IN T H E R E V IE W
[ P IC OS ]
3.1.1 Types of studies
Interventions targeting outcomes for street-connected children and young
people have used a variety of approaches and designs. We will include
randomised controlled trials (RCTs), clinical controlled trials (CCTs), controlled
before-and-after trials (CBA), interrupted time-series studies (ITS) and quasi-
randomised trials. With quasi-randomised trials we refer to studies which
allocate the children and young people to treatment/control conditions
depending on methods determined as not truly randomised, for example, on
their date of birth or the day of the month they enter the intervention site.
Where retrieved studies include other nonrandomised designs, such as
regression discontinuity designs, the aim will be to include them where it is
possible to access appropriate methodological input.
Even though we do not aim to synthesise papers discussing the needs and issues
of street-connected children and young people and best practice
recommendations, we aim to use such literature in order to identify possible
explanatory variables that function as mediating or moderating variables in the
relationship between the intervention and the outcome of the intervention.
We will not include qualitative data in our outcomes synthesis. However, we
used qualitative intervention evaluations in order to design the logic model and
will continue developing the logic model with the help of qualitative data and
the identified included studies in the progress of the review. We will also use
qualitative data, including sibling or companion studies of included quantitative
studies, to illuminate the impact of context and also mechanisms of change and
any process factors. We will not conduct separate searches for qualitative
literature, other than for companion studies of included studies and those
needed to highlight any particular questions arising in relation to context,
mechanisms, and process, etc., according to themes outlined in the logic
models. The best way to locate these studies will be to retrieve them from the
list of references or from studies citing the study. We will include both elements
in the search. In addition, we plan to contact authors directly, requesting
information on companion studies.
3.1.2 Types of participants
We aim to include all studies focussing on street-connected children and young
people between the ages of 0 and 24 years (inclusive), as consistent with the
12 The Cam pbell Collaboration | www.cam pbellcollaboration.org
United Nations' (UN) definition of youth as including those aged 15 to 24,
regardless of location, reason for street connectedness or gender. Research
participants include: street-connected children and young people, their
families/carers, professionals working with children, young people and their
families, the police, and employers.
Street-connected children and young people, and possibly their families/carers
will be the intervention recipients. Families and carers are included as potential
intervention recipients, firstly because street-connected children and young
people remain members of families and also because some interventions (such
as conditional cash transfers) might be targeted at families to promote school
attendance, literacy, and reintegration of the children. However, we will exclude
any studies that do not report separate outcomes data on street-connected
children and young people in the context of systemic interventions.
Families/carers, the community, professionals, and employers may also be
involved in the delivery of interventions. Families/carers, the community,
employers, and professionals will be an important part of the ‘input’ component
of the intervention to the extent that they are needed to support the
intervention and are part of it. Our definition of professionals and community
will include NGOs, faith-based organisations, orphanages, social workers, and
For the purposes of this review we define street-connected children as in
Description of the intervention above: "Children and young people may live and
work on the street or in public spaces, work on the street and return to family
homes or hostels at night, or a combination of these at different time periods.
For the most part, they experience complex social and economic circumstances
that ‘defy easy definition’ (CSC 2011). Current thinking sees this process as non-
linear, with many street-connected children and young people transitioning off
the streets, more than once, with this also, a non-linear process".
3.1.3 Types of Interventions
We will include any interventions that:
• involve harm-reduction, inclusion or reintegration programmes for street-
connected children and young people, intended to reduce harms associated
with risky sexual activity and substance misuse;
• increase literacy, numeracy and self-esteem;
• increase participation in education and skills-based employment;
• provide shelter, housing and drop-in support.
We will include any type of intervention including behavioural, social, policy,
structural, or other interventions explicitly aimed at reducing risky sexual
activity and substance misuse. Interventions may be delivered to individuals,
families, small groups or entire communities. Furthermore, recognising the
complexity of the issues facing many street-connected young people, there has
been a developing focus on multifaced interventions that incorporate a range of
approaches including housing, education, training and health (De Benitez
13 The Cam pbell Collaboration | www.cam pbellcollaboration.org
For this review, the included studies require a comparator; either groups who
do not receive an intervention, who receive standard practice interventions, or
who receive a different type of intervention. Where relevant, we will also
examine the relative effects of different intervention components.
3.1.4 Types of outcome measures
Since a recent Cochrane review and a systematic review conducted for the
WHO have evaluated AIDS and HIV as target outcomes (Naranbhai 2011; Ross
2006) we will not include AIDS and HIV risks as outcome variables. However,
we will assess to what degree the included studies of these reviews overlap with
our scope/population and if relevant, we will consider the trends in the results
of these reviews when interpreting the results of our review.
22.214.171.124 Primary outcomes
The primary outcomes will be inclusion and reintegration (reintegration by the
above definition does not mean returning children to situations from which
they may have escaped).
126.96.36.199 Secondary outcomes
We will also extract the following analysable data of other related measures of
health, well-being and educational/occupational achievement.
1. Safer or reduced sexual activity.
2. Safer or reduced substance use (e.g. reduced sharing of injecting
3. Increased use of hostel/shelter type services.
8. Participation in education.
9. Participation in skills-based (rather than exploitative) employment.
Reduced use of violence.
11. Increased contact with family.
12. Participation in intervention planning and delivery.
We will include intervention studies if they aim to achieve any one of the listed
primary or secondary outcomes, or both. Secondary objectives may be
particularly relevant where interventions are administered within an existing
service setting. A cursory glance at the evidence we obtained from our
preliminary searches seems to indicate that there are not many eligible studies;
a requirement of including only studies that aim to achieve all of our stated
outcomes would probably result in a very small number of eligible studies, or
We will extract measures relating to the process of implementing an
intervention and intervention approaches. We will also extract information
consistent with the characteristics listed in the logic model in order to develop
an explanatory framework.
14 The Cam pbell Collaboration | www.cam pbellcollaboration.org
We will include a descriptive map of all studies considered for eligibility for
inclusion in the review, in order to present as fully as possible a description of
the existing evidence base in this topic. We will include this as adjunctive to the
main review in the interests of completeness of data, rather than being used as
a tool for narrowing the review focus.
3.2 S E A R C H M E T H OD S F OR ID E NT IF IC A T ION OF S T U D I E S
3.2.1 Search methods for identification of studies
We have worked with information specialists from Campbell’s International
Development Co-ordinating Group and the Cochrane Musculoskeletal Group to
develop a search strategy.
W e will use the following search strategy in MEDLINE:
Database: Ovid MEDLINE(R) In-Process and Other Non-Indexed Citations and
Ovid MEDLINE(R) <1948 to Present>
1 "Homeless Youth"/ or (homeless$ adj2 (child$ or youth$ or young or teen$ or
2 "Runaway Behavior"/
4 (street adj4 kids).tw.
5 (street adj4 youth).tw.
6 Child, Abandoned/
7 abandoned child$.tw.
8 Child, Orphaned/
9 (orphan$ adj3 child$).tw.
10 Child, Unwanted/
11 (unwanted adj4 child$).tw.
12 (street adj4 child$).tw.
13 Criancas de rua.tw.
14 Meninos de rua.tw.
15 (street adj3 urchins).tw.
16 (Pavement adj3 dweller$).tw.
17 (railway adj2 children).tw.
18 (unaccompanied adj4 (refugee$ or migrant$)).tw.
19 (unaccompanied adj4 minor$).tw.
21 (niños adj3 calle).tw
22 (ninos adj3 calle).tw
15 The Cam pbell Collaboration | www.cam pbellcollaboration.org
23 (enfants adj3 rue).tw
24 (jeunes adj3 rues).tw
39 young people.mp.
48 Infant, Newborn/
16 The Cam pbell Collaboration | www.cam pbellcollaboration.org
63 exp Vulnerable Populations/
64 human trafficking.mp.
67 Homeless Persons/
69 (human adj4 traffick$).tw.
70 (sex adj4 trade).tw.
71 (sex adj4 work$).tw.
73 (62 and 72)
74 73 or 25
75 exp animals/ not humans.sh.
76 74 not 75
3.2.2 Electronic searches
We will search the following bibliographic databases for eligible empirical studies
published between the databases' inception and the search date:
Cochrane Central Register of Controlled Trials (CENTRAL) (database inception to
MEDLINE and PreMEDLINE (1948 to search date)
EMBASE and EMBASE Classic (1947 to search date)
CINAHL (1966 to search date)
PsycINFO (1806 to search date)
ERIC (1950 to search date)
Sociological Abstracts (1952 to search date)
Social Services Abstracts (1979 to search date)
Social Work Abstracts (1977 to search date)
Healthstar (1966 to search date)
LILACS (database inception to search date)
System for Grey literature in Europe (OpenGrey) (database inception to search date)
ProQuest Dissertations and Theses (database inception to search date)
EconLit (1969 to search date)
IDEAS Economics and Finance Research (database inception to search date)
J OLIS Library Catalog of the holdings of the World Bank Group and IMF Libraries
(database inception to search date)
BLDS British Library for Development Studies (1987 to search date)
Google, Google Scholar - we will record search terms used, the search date, and we
will the first 50 results per search.
17 The Cam pbell Collaboration | www.cam pbellcollaboration.org
We will screen items suggested by experts and authors of included studies, including
We will not limit the search by outcomes, however we will apply the inclusion
criteria at the screening phase. We will not limit the searches by language.
3.2.3 Searching other resources
We will screen items suggested by experts, advisory group members, and authors of
included studies, including companion studies. We will also check reference lists of
included studies from the electronic database search. We will use search terms from
the electronic search which describe our population, and adapt them as appropriate
to search the Internet-based resources. We will use relevant studies to perform a
citing studies search using SCOPUS or Web of Science and PubMed’s related article
function to track references to the included articles, relevant reviews and annotated
We will contact experts in the field, including the top five authors identified via the
We will conduct a targeted Internet search on the following relevant sites:
tion%20to%20search%20methods/Specialist_ health_ economics_ literature_ databa
§ J -PAL website
§ UNICEF database of evaluations
§ Eldis http://www.eldis.org/
§ Department for International Development http://www.dfid.gov.uk/
§ Inter-American Development Bank http://www.iadb.org
§ Asian Development Bank http://www.adb.org
§ African Development Bank http://www.afdb.org
We will not limit the search by outcomes; we will apply the inclusion criteria at the
screening phase. We will not limit the searches by language. We will search the
tables of contents of books on street children for relevant chapters. Examples of
books that we will include in the search are Ennew 2000 and HRW 1996.
We will also search for published or unpublished studies by identifying contacts and
literature via ‘snowballing’ techniques (following one link that leads to another) and
bibliographic back-referencing of studies identified for review. We will make email
contact with individuals and organisations working in this field.
We will handsearch the last 12 months of the five journal titles appearing most
frequently in the list of selected papers, and will search the websites of organisations
actively involved in interventions for street children (such as Save the Children,
UNICEF, Consortium for Street Children (CSC) and INSSW (International Network
of Social Street Workers)).
18 The Cam pbell Collaboration | www.cam pbellcollaboration.org
D A T A C OL L E C T ION A ND A NA L Y S IS
Selection of studies
The initial search strategy is expected to produce a listing of several thousand
citations. At least two authors will undertake an initial screening of titles and
abstracts to remove those which are obviously outside the scope of the review;
they will be over-inclusive at this stage. We will obtain and scrutinise full
manuscripts of shortlisted studies to establish eligibility based on design,
participants, intervention, and outcomes reported by two independent
reviewers. For the English language literature, EC and RH working with a local
team will establish study eligibility. In case of ambiguity not resolved with the
third reviewer (J PP), we will contact the authors of the original manuscript for
further information. For Spanish and Portuguese language literature, J PP and
MV will establish study eligibility, with EC acting as a third reviewer who will
be involved in ambiguous cases. For literature in other languages, we will
determine eligibility by English language abstracts, and where necessary, by
translation into English or Spanish/Portuguese. We will maintain records of
eligibility adjudication, exclusion and inclusion per normal Cochrane
guidelines (Higgins 2011).
Data extraction and management
We will include all studies considered eligible in the review. Two independent
reviewers (EC and RH) will extract the data from eligible studies on
standardised data collection forms and will enter these data in Review Manager
5 using double-data entry (RevMan 2011). We will tailor the data extraction to
the requirements of this review, using the PROGRESS II checklist as developed
by the Cochrane-Campbell Equity Methods Group (Kavanagh 2008), and
working to the logic model. We will assemble and compare multiple reports
and publications of the same study for completeness and possible
contradictions, and extract data from companion studies that report findings
on the process evaluation of the intervention. Three review authors will pilot
the data extraction form to assess its ability to capture study data and inform
assessment of study quality. We will resolve any problems indentified through
discussion and will revise the form, as required.
Assessment of risk of bias in included studies
Two review authors (English literature: EC, RH; Spanish/Portuguese
literature: J PP, MV) will assess the risk of bias. For analysis of non-RCTs, we
will follow the recommendations in Chapter 15 of the Cochrane Handbook for
Systematic Reviews of Interventions (Higgins 2011). In case of disagreement
between reviewers’ risk of bias assessment, a third review author will appraise
the study independently and the three review authors will resolve any
discrepancies. This third reviewer for the English language literature will be
J PP, and for the Spanish/Portuguese literature will be EC. We will assess the
risk of selection, performance, attrition, and detection bias. We will evaluate
19 The Cam pbell Collaboration | www.cam pbellcollaboration.org
and rate as ‘adequate’, ‘inadequate’ and ‘unclear’, sequence generation,
allocation concealment, blinding of participants, personnel and outcomes,
incomplete outcome data, selective outcome reporting, and other sources of
bias. In the case of disagreements, we will consult a third reviewer to resolve
Measures of treatment effect
We will express the effect sizes for dichotomous outcomes as a risk ratio (RR) in
the first instance. We will use the weighted mean difference (WMD) between
the postintervention values of the intervention and control groups to analyse
the size of the intervention effects for continuous outcomes. In addition, for
outcomes measured on different scales, we will use the standardised mean
Where possible, we will report continuous outcomes on the original scale. We
will standardise outcomes measured on different scales as required for the
analysis. We will only conduct a meta-analysis if the data are sufficiently
similar. If data are available, sufficiently similar and of sufficient quality we will
perform statistical analyses using Review Manager 5 software (RevMan 2011).
We will not combine evidence from differing study designs and outcome types
in the same forest plot.
Unit of analysis issues
In order to avoid double-counting where a study presents results for several
periods of follow-up, we will undertake separate meta-analyses for the various
time points: immediate post-test, six month follow-ups and 12 month follow-
ups. Where a study presents data from a different time point to the other
studies, we will present these data separately.
Where multiple treatment/control group types are presented in study reports,
we will seek to present the data from each study as consistently as possible with
the primary comparison of treatment compared with the control group. We will
present and separately analyse data from studies comparing different types of
If cluster designs arise, we hope that study investigators present their results in
the units in which participants were analysed. Where it is unclear whether this
has taken place, we will contact the study authors for further information. If we
are unable to obtain further information, we will seek statistical guidance from
the review group as to which method to apply to the published results in order
to manage data errors arising from clustering, for example by identifying an
intra-class correlation coefficient to utilise in adjusting the data.
Dealing with missing data and incomplete data
Due to the fluctuating nature of attendance at likely programmes, we will not
exclude according to degree of incomplete data for assessment, but will
incorporate this both narratively and in the risk of bias assessment. At data
extraction stage, if missing data are unclear or have not been fully reported, we
will contact the authors. In general, we will report the occurrence of missing
20 The Cam pbell Collaboration | www.cam pbellcollaboration.org
data both in the data extraction form and in the risk of bias table, while the data
extraction form will also capture where missing data have been retrieved.
D A T A S Y NT H E S IS
Where possible, we will report continuous outcomes on the original scale. We
will standardise outcomes measured on different scales, as required for the
analysis. We will report binary outcomes as risk ratios in the first instance.
If data are available, sufficiently similar, and of sufficient quality we will
perform statistical analyses using Review Manager 5 software (RevMan 2011),
using a random-effects model. We will not combine evidence from differing
study designs and outcome types in the same forest plot.
We will analyse the synthesis of data from studies not included in statistical
analyses according to features of the logic model, extracted through the data
extraction process. We will group data according to the aims and outcomes of
the interventions, as well as according to contexts, particularly regarding
income status and cultural environment of the different countries included in
the review. We will further consider groupings around age, gender, ethnicity,
and where possible, the reasons for children and young people being street-
connected (e.g. migration status, economic activity, history of abuse).
Assessment of heterogeneity
We will assess homogeneity using the Chi2 tests, with a P < 0.01, and use the I2
statistic to assess statistical heterogeneity. We may conduct subgroup analyses
as a means of investigating heterogeneous results.
The review implies considerable heterogeneity as we will include studies from
diverse settings and contexts, in particular from countries with very differing
levels of income and development, and different cultural and religious
environments. As noted elsewhere, we will consider all aspects of
heterogeneity; we intend to make full use of the logic model to assist us in
teasing out different elements of treatment effect, and will be seeking advice
from experts in relation to confounding factors. Whilst that is primarily for
quality appraisal of nonrandomised studies, it will be of importance in
considering heterogeneity as well.
At this stage, we do not envisage the possibility of conducting a meta-analysis,
and so it is unlikely that assessments of statistical heterogeneity will have any
bearing on synthesised point estimates, but rather on the spread and direction
of effect of any numerical data, which we will be analysing discursively. If we
do perform a meta-analysis, it is likely that due to the anticipated
heterogeneity, we will use a random-effects model.
Subgroup analysis and Investigation of H eterogeneity
If sufficient studies are included to make this meaningful, we will explore
heterogeneity by analyses per subgroup for populations that are significantly
dissimilar. These analyses may include analyses by age, gender, location of
studies, high, low and middle income countries and intervention approaches.
21 The Cam pbell Collaboration | www.cam pbellcollaboration.org
We will identify a comprehensive range of subgroups relevant to low and
middle income countries, and incorporate effects of subgroup characteristics
into our logic models.
As the studies are likely to vary methodologically, for example, in terms of
allocation concealment, we will conduct a sensitivity analysis to discover the
influence of these variations on the summary measures, in particular the
overall quality assessment and risk of bias assessed in each study.
We will also test the robustness of findings using sensitivity analysis to
consider any differences in findings arising between studies conducted in high
income countries and in low and middle income countries. We will assess
differences between studies according to national income levels for all data
types included in the review, and regardless of the ability to conduct a
Assessment of Publication Bias
If a sufficient number of studies are found we will investigate reporting biases
using a funnel plot. We will also address narratively any imbalance within the
included studies in both the conduct of evaluations and publication of reports
between high income and low and middle income countries.
Our study selection includes RCTs, as well as controlled before-and-after (CBA)
studies and other nonrandomised designs that include a control or comparison
group. To assess risk of bias, we will therefore use the risk of bias tool
developed by the Cochrane Effective Practice and Organisation of Care (EPOC)
Group (EPOC 2009), which lends itself to a range of studies with a separate
control group (with the exception of interrupted time series (ITS) studies). This
tool includes the standard Cochrane risk of bias tool items, as well as an
additional item to consider the likelihood of contamination. Importantly for
nonrandomised studies, it also includes additional items to assess the risk of
selection bias and subsequent confounding (‘were baseline outcome
measurements similar?’ and ‘were baseline characteristics similar?’). We will
supplement this with another additional item, ‘did the study authors
appropriately adjust for important confounders in their analysis?’. The review
team, advisory group and other experts will approve an agreed list of
22 The Cam pbell Collaboration | www.cam pbellcollaboration.org
Thanks are due to the advisory group members who have contributed their wisdom
to the development of the protocol: Sarah Thomas de Benitez, Harriot Beazley,
Nicole Howard, Christopher Hands, Petra Englebrecht, Anna-mai Estrella, Angeles
Fiallo Montero, Claudia Stoicescu, J oe Walker, Louise Meincke, and Damon Barrett.
Thanks also to Tamara Rader from the Campbell Collaboration International
Development Co-ordinating Group and the Cochrane Musculoskeletal Group for
assistance in developing the search strategy, and to J odie Doyle of the Cochrane
Public Health Group for assistance with the process.
23 The Cam pbell Collaboration | www.cam pbellcollaboration.org
5 R eferences
Ali M, Shahabb S, Ushijimaa H, De Muynck. Street children in Pakistan: a situational
analysis of social conditions and nutritional status. Social Science and Medicine
Altena AM, Brilleslijper-Kater SN, Wolf J L. Effective interventions for homeless youth: a
systematic review. American J ournal of Preventive Medicine 2010;8(6):637-45.
Anderson LM, Petticrew M, Rehfuess E, Armstrong R, Ueffing E, Baker P, et al. Using logic
models to capture complexity in systematic reviews. Research Synthesis Methods 2011;2:33-
Beazley H. Voices from the margins: street children’s subcultures in Indonesia. Children’s
Consortium for Street Children. Street Children: a mapping and gapping review of the
literature 2000 to 2010. www.crin.org/docs (accessed 7 February 2012).
Consortium for Street Children. Street Children Statistics. London: CSC, 2009.
De Benitez 2008
De Benitez TS, J ones G. Youth on the streets. Briefing note on youth. www.un.org/youth/
(accessed 1 August 2011).
Dybicz P. Interventions for street children: an analysis of current best practices.
International Social Work 2005;48(6):763–71.
Ennew J . Street and Working Children: A Guide to Planning. London: Save the Children,
Ennew J , Swart-Kruger J . Introduction: homes, places and spaces in the construction of
street children and street youth. Children, Youth and Environments 2003;13(1):1-21.
Effective Practice and Organisation of Care Group. Risk of bias.
www.epoc.cochrane.org/epoc-author-resources (accessed 7 February 2012).
Gleghorn AA, Clements KD, Marx R, Vittinghoff E, Lee-Chu P, Katz M. The impact of
intensive outreach on HIV prevention activities of homeless, runaway, and street youth in
San Francisco: The AIDS evaluation of street outreach project (AESOP). AIDS and Behavior
H iggins 2011
24 The Cam pbell Collaboration | www.cam pbellcollaboration.org
Higgins J PT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions
Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from
H R W 1996
Human Rights Watch. Police Abuse and Killings of Street Children in India.
www.unhcr.org/refworld/docid/3ae6a7eb0.html (accessed 7 February 2012).
K arabanow 2004
Karabanow J , Clement P. Interventions with street youth: a commentary on the practice-
based research literature. Brief Treatment and Crisis Intervention 2004;4(1):93-108.
K avanagh 2008
Kavanagh J , Oliver S, Lorenc T. Reflections on developing and using PROGRESS-Plus Equity
Update. www.equity.cochrane.org/Files/Equity_ Update_ Vol2_ Issue1.pdf 2008;2(1):1-3.
K ellogg Foundation 2004
Kellogg Foundation. Logic model development guide. www.wkkf.org/knowledge-
(accessed 7 February 2012).
K ipke 1997
Kipke MD, Unger J B, Palmer R, Edgington R. Drug-injecting street youth: a comparison of
HIV-risk injection behaviours between needle exchange users and nonusers. AIDS and
K ristof 2009
Kristof ND, WuDunn S. Half the Sky: How to Change the World. London: Virago Press,
Moore J ; National Center for Homeless Education. Unaccompanied and homeless youth:
review of literature (1995-2005). center.serve.org/nche/downloads/uy_ lit_ review.pdf
(accessed 7 February 2012).
Naranbhai V, Abdool Karim Q, Meyer-Weitz A. Interventions to modify sexual risk
behaviours for preventing HIV in homeless youth. Cochrane Database of Systematic Reviews
2011, Issue 1..
Ouma WG. Education for Street Children in Kenya: The Role of the Undugu Society. Paris:
International Institute for Educational Planning, 2004.
Panter-Brick C. Street children, human rights, and public health: a critique and future
directions. Annual Review of Anthropology 2002;31:147-71.
Peters DH, Mirchandani GG, Hansen P. Strategies for engaging the private sector in sexual
and reproductive health: how effective are they? Health Policy and Planning 2004;19(Suppl
Poland BD, Tupker E, Breland K. Involving street youth in peer harm reduction education.
Canadian J ournal of Public Health 2002;93(5):344-8.
R edes R io Crianca 2007
Redes Rio Crianca. Crianca, Rua e ONGs: Quem Faz o que faz? Mapeamento de Acoes Das
ONGs J unto as Criancas e adolescentes em situacao de rua no municipio do RJ [Childhood,
Street and NGOs: Who are they and what do they do? Mapping of NGO Activities Working
with Children and Adolescents in Street Situations in the Municipality of Rio de J aneiro. Rio
de J aneiro: Criacao Grafica, 2007.
R evMan 2011
25 The Cam pbell Collaboration | www.cam pbellcollaboration.org
Review Manager (RevMan) [Computer program]. Version 5.1. Copenhagen: The Nordic
Cochrane Centre, The Cochrane Collaboration, 2011.
R oss 2006
Ross DA, Dick B, Ferguson J . Preventing HIV/AIDS in young people: a systematic review of
the evidence from developing countries. WHO Technical Report Series.
www.unicef.org/aids/files/PREVENTING_ HIV_ AIDS_ IN_ YOUNG_ PEOPLE_ _ A_ SYSTE
MATIC_ REVIEW_ OF_ THE_ EVIDENCE_ FROM_ DEVELOPING_ COUNTRIES_ WHO_ 20
06.pdf (accessed 7 February).
R otheram-Borus 2003
Rotheram-Borus MJ , Song J , Gwadz M, Lee M, Van Rossem R, Koopman C. Reductions in
HIV risk among runaway youth. Prevention Science 2003;4(3):173-87.
Sanabria J J . Youth homelessness: prevention and intervention efforts in psychology.
Universitas Psychologica 2006;5(1):51-67.
Slesnick N, Prestopnik J L, Meyers RJ , Glassman M. Treatment outcome for street-living,
homeless youth. Addictive Behaviours 2007;32:1237-51.
Theron LC, Malindi MJ . Resilient street youth: a qualitative South African study. J ournal of
Youth Studies 2010;13(6):717-36.
Thoburn J . Reunification from care: the permanence option that has most to offer, but the
lowest success rate. Seen and Heard 2009;18(4):44-53.
UNICEF. A study on street children in Zimbabwe.
www.unicef.org/evaldatabase/index_ 14411.html (accessed 7 February 2012).
UNICEF. Rapid situation assessment report on: the situation of street children in Cairo and
Alexandria, including the children’s drug abuse and health/nutritional status.
www.unicef.org/evaldatabase/index_ 14268.html (accessed 7 February 2012).
UNICEF. The State of the World’s Children 2003. NY: UNICEF, 2002.
UNICEF. The State of the World’s Children 2006. NY: UNICEF, 2005.
Van Blerk 2006
Van Blerk L. Diversity and difference in the everyday lives of Ugandan street children: the
significance of age and gender for understanding the use of space. Social Dynamics
W alker 2011 [pers comm]
Walker J . Systematic review on street children - advisory group [personal communication].
Email to: E Coren. 17 August 2011.
W est 2003
West A. At the margins: street children in Asia and the Pacific.
www.adb.org/Documents/Papers/Street_ children_ _ Asia_ Pacific/SC_ final.pdf (accessed 7
W H O SEK N 2008
Popay J , Escorel S, Hernández M, J ohnston H, Mathieson J , Rispel L; WHO SEKN (Social
Exclusion Knowledged Network). Understanding and tackling social exclusion: final report
to the WHO Commission on social determinants of health from the social exclusion
26 The Cam pbell Collaboration | www.cam pbellcollaboration.org
www.who.int/social_ determinants/knowledge_ networks/final_ reports/sekn_ final%20repo
rt_ 042008.pdf (accessed 7 February 2012).
27 The Cam pbell Collaboration | www.cam pbellcollaboration.org
7 Figures [if any, otherwise delete]
Figure text: Title of figure
28 The Cam pbell Collaboration | www.cam pbellcollaboration.org
Figure text: Title of figure
29 The Cam pbell Collaboration | www.cam pbellcollaboration.org
8 Contribution of Authors
Esther Coren (EC), Rosa Hossain (RH), and Manuela Thomae (MT) drafted the
protocol with input from other authors and from the advisory group. J ordi
Pardo Pardo (J PP) developed the search strategy with input as above and
consulted on the development of the logic model. Mirella MS Veras (MV)
contributed to refining the search and Portuguese language terms, and will be
closely involved in detailed screening of Spanish and Portuguese language texts
retrieved in the search. Kabita Chakraborty (KC) contacted organisations and
NGOs in the field for unpublished data, and made a contribution to screening.
30 The Cam pbell Collaboration | www.cam pbellcollaboration.org
9 Declarations of Interest
Research discussed in this publication has been funded by the International
Initiative for Impact Evaluation, Inc. (3ie) through the Global Development Network
(GDN). The views expressed in this article are not necessarily those of 3ie or its
members, or of GDN.
31 The Cam pbell Collaboration | www.cam pbellcollaboration.org Download full-text
10 Sources of support
10 .1 INT E R NA L S OU R C E S
No sources of support provided
10 .2 E X T E R NA L S OU R C E S
3ie, Not specified
Funding to support the project